1. Field of the Invention
The present invention relates to a system and methods for medical analysis and more particularly, it relates to an early warning trigger analysis system used as an automated mechanism for the early warning detection of patient health risk.
2. Background of the Invention
The concerns about medical errors and clinical quality are increasing. In fact, a 1999 study by the Institute of Medicine of the National Academy of Sciences estimates that 1.5% to 2.0% of all hospital admissions in the United States result in a significant and preventable adverse event that was caused by the medical establishment. The study estimates that medical mistakes are the eighth leading cause of death in the United States. The delivery of clinical care often involves complex analysis and the evaluation of multiple treatment options. However, many physicians report that, due to the rapid pace of medical innovation and the volume and complexity of medical information directed at them, they have difficulty keeping up with state of the art medical practices and other developments in their areas of specialization.
The public and the media have also become increasingly concerned with healthcare quality. For example, it has been reported that as few as 5% of people in the United States with heart failure receive the appropriate therapy. Further, it is estimated that this failure to apply an optimal therapy results in an estimated 100,000 premature deaths from this condition that otherwise might not have occurred.
Another problem with the health care system is that incomplete patient clinical data leads to inefficiencies and lapses in patient care. All participants in the healthcare system rely heavily on information and often depend on other participants for the information they need to perform their roles. However, individual care is delivered and paid for in numerous locations by individuals and organizations that are often unrelated. As a result, critical patient data is stored in many different locations using incompatible and proprietary legacy mainframe and client-server systems that store information often in non-standardized formats. To diagnose and treat a patient properly, providers must often request patient information by phone or fax from hospitals, laboratories or other providers. The delivery of this information is often delayed and may be incomplete due to the disparate systems maintained by those constituents.
This industry fragmentation and the resulting lack of comprehensive patient information are primary reasons for inefficiencies and lapses in patient care. These inefficiencies and lapses may lead to medical mistakes, poor clinical outcomes and excess costs due to: inconsistent, incomplete or inaccurate diagnoses; redundant tests; inappropriate medications; increased potential for medical errors and clinical complications; and failure to apply optimal therapies and adequate follow-up.
Healthcare expenditures continue to rise and it is estimated that healthcare expenditures currently represent $1.2 trillion, or 14%, of the U.S. economy, and that these expenditures will continue to increase to $2.2 trillion in 2008, an 8% compound annual growth rate, both because of rising healthcare costs and the increasing medical demands of an aging population.
Further, it is also estimated that over $250 billion dollars are wasted each year through the delivery of unnecessary care, performance of redundant tests or procedures and excessive administrative costs. As a result, the government and other purchasers of healthcare have increasingly placed pressure on the industry to improve the quality and cost-effectiveness of healthcare. To date, health plans have primarily focused on gaining price concessions from providers and suppliers and limiting access to healthcare products and services. Recently, consumers, providers and policymakers have begun to question this managed care approach. Patients and their employers have expressed dissatisfaction with escalating health plan premiums and xe2x80x9cgatekeeperxe2x80x9d style plans that limit physician choice and access to healthcare services. Physicians and patients have expressed concern that managed care has led to a decline in the quality of patient care.
Another problem is that current healthcare information technology approaches do not address the majority of healthcare costs. Information technology and the Internet have become increasingly important tools to manage rising costs in the healthcare industry. However, current healthcare information technology products and services, including many e-health initiatives, focus primarily on changing administrative and financial processes, such as streamlining billing and purchasing, or maximizing reimbursement. Very few of these initiatives address unnecessary or inappropriate clinical care or the overall quality of clinical care. In addition, these administrative-oriented efforts address only the 15% of healthcare expenditures that relate to administrative costs and do not address the 85% of expenditures that relate to clinical costs.
In addition all participants in the healthcare system rely heavily on information and often depend on other participants for the information they need to perform their roles. However, individual care is delivered and paid for in numerous locations by individuals and organizations that are often unrelated. As a result, critical patient data is stored in many different locations using incompatible and proprietary legacy mainframe and client-server systems that store information often in non-standardized formats. To diagnose and treat a patient properly, providers must often request patient information by phone or fax from hospitals, laboratories or other providers. The delivery of this information is often delayed and may be incomplete due to the disparate systems maintained by those constituents.
Therefore what is needed is a healthcare management system which improves the quality of care, better manages healthcare costs, provides healthcare organizations and physicians information to make accurate diagnosis and treatment, and provides a communications link for information, forms, patients, healthcare organizations and physicians.
The present invention counters the problems associated with healthcare management by providing a clinically sophisticated, comprehensive solution to improve the quality and manage the costs of care. The present invention includes software applications and services that are broadly organized under three product/service offerings including: (i) application tools for identifying potentially problematic patient cases before they become effective problems, (ii) case and disease management applications and programs for managing problematic and complex cases and (iii) applications and services to improve overall risk underwriting profitability.
The foundations of the present invention are its unique data repository and its proprietary Care Engine(trademark), multi-dimensional analytical software tool. The Care Engine software tool is developed around broad categories of diseases and treatments, with defined elements called matrices. The present invention has been developed together with a panel of board-certified medical specialists and encompasses an array of care management functions, including: (1) screening patient populations; (2) finding and stratifying high-risk patients within a population; (3) identifying potential misdiagnoses or errors in care; (4) providing information that enables physicians to improve the care of poorly managed or misdiagnosed patients; (5) creating software tools for the case management of patients with complex, acute or chronic diseases; and (6) providing predictive tools to improve the accuracy of healthcare risk underwriting.
The present invention may be provided through an application service provider model either as a complete care management solution or separately, depending on the customer""s needs. The present invention users will include self-insured employers, payers, and TPAs.
The present invention securely aggregates and standardizes clinical data derived from a variety of sources and stores it on a patient-specific basis in a unique data repository, called the DataVault. As seen in FIG. 1 these data types include laboratory test results 103, prescription drug data 101, health plan claims data 105, and in-patient information and notes 107. The laboratory test results 103, prescription drug data 101, health plan claims data 105, and in-patient information and notes 107 can be sent to an analytical portion of the system through a data link 109. Once the various different kinds of data are sent they are stored in a Data Vault 110. The analytical portion of the present invention is the Care Engine 112 which is used to analyze a patient""s available medical history. The Care Engine 112 identifies potential diagnostic or treatment errors to enable timely modification to treatment regimens. The Care Engine 112 can also find individuals and stratify populations by numerous-adjusted disease criteria and co-morbidities, allowing customers to assess the need for and implement appropriate disease or case management programs. The present invention also uses a screening element 115 which allows medical staff to review or screen potential diagnostic or treatment errors discovered by the Care Engine 112.
In addition, the present invention may incorporate secure, individual patient Web pages, which it calls Private Health Records 130, that are designed to educate and empower individuals to participate in healthcare decisions and may include customers, physicians, and patients. The Private Health Records 130 would be available through a system portal 120 and web browser 125. The Care Engine 112 will automatically populate a patient""s Private Health Record 130 with information stored in the DataVault 110. However, the screening element 115 will filter out information corresponding with the type of user such that only that information for which they are provided access to can be viewed.
Another failure of the system of the present invention includes a rules-driven, Internet-based, easily customizable process, or workflow, software platform that is delivered over the Internet. Customers may use this platform to create and develop nurse-supported case management and disease management programs for patients with complex, acute or chronic diseases.
The system is also designed to predict medical care costs within a covered population by using epidemiological and demographic data, as well as the clinical data aggregation and analysis capabilities provided by the DataVault 110 and Care Engine 112. Customers would use these products and services to assess the potential cost savings of different disease management strategies and clinical interventions, and identify the members of a covered population who are being medically mismanaged and whose associated medical costs could be affected by timely treatment intervention.
The present invention offers a comprehensive solution to care management which: aggregates, integrates and stores clinical information from disparate sources; finds at-risk individuals for case management before they experience preventable, high-cost medical events; stratifies high risk populations according to clinical criteria, which can include severity of disease states and co-morbidities; compares the actual care an individual is receiving to established standards of clinical excellence and, if necessary, suggests pertinent medical care considerations to improve the care of medically mismanaged individuals; creates a secure, patient-specific Web page that is automatically populated with a patient""s own clinical information and further personalizes with customized, relevant healthcare information; allows users to design, facilitate and monitor clinical care plans and increase communications among physicians, nurses and patients; and predicts and analyzes the outcome of disease or case management for populations and individual patients.